At-need Information Form | Glunt Funeral Home

Does the Decedent have a Prearrangement on file with us?

Information About the Individual this prearrangement form is for?

Information About the Individual this prearrangement form is for?

First Name:*

Middle Name:

Last Name:*

Maiden Name (if applicable):

Nickname:

Could the person have gone by any other names?

Yes

No

Last Permanent Address

Address

Street:

City:

State/Province:

Zip/Postcode:

County

Is the address in the City or Borough Limits?

Yes

No

If NO, which Township?

Additional Information about the Decedent

Additional Information about the Individual

Date of Birth:

City of Birth:

State of Birth:

Social Security Number:

Ethnic Origin:

Specify Other Ethnic Origin

Gender:

Education

Education

Highest Level of Education

High School Attended & year Graduated

College(s) Attended & year Graduated:

Occupation

Occupation

Usual Occupation:

Type of Industry:

Work History:

Retired from Working?

Yes

No

Free Text

Hobbies, Interests, Clubs and Associations

Hobbies & Interests

Clubs & Associations

Marital Status

Marital Status

Marital Status:

Spouse's - First Name:

Middle Name:

Current Last Name:

Maiden Name (If applicable):

Spouse's Date of Birth:

Social Security Number:

Phone Number:

Does the Spouse Live at the same address?

Yes

No

Parents of the Decedent

Parents of the Individual

Father's First Name:

Middle Name:

Last Name:

Father Living/Deceased

Living

Deceased

Mother's First Name:

Middle Name:

Last Name:

Maiden Name:

Mother Living/Deceased

Living

Deceased

Children of the Decedent

Children of the Individual

Living Sons:

Deceased Sons:

Living Daughters:

Deceased Daughters:

Other Members of the Family

Siblings

Living Brothers:

Deceased Brothers:

Living Sisters:

Deceased Sisters:

Living Grandchildren:

Deceased Grandchildren:

Living Great- Grandchildren:

Deceased Great-Grandchildren

Other Living Relatives or Special Individuals

Other Deceased Relatives or Special Individuals

Funeal Service Choices

Funeral Service Choices

Depending on the schedule of the funeral home, not all dates may be available for visitation or calling hours.

Visitation Options:

Would you like to have visitation?

Preferred Times:

Funeral or Memorial Service

Funeral or Memorial Service Options

Would this person like to have a funeral or memorial service

Preferred time for service:

Religion

Religion

Does this person have any religious affiliations?

Yes

No

Unknown

Preferred Church:

Preferred Minister:

Final Disposition

Final Disposition

Would this person prefer burial or cremation

What would this person like their final disposition to be?

Does this person have a cemetery lot?

Cemetery Name

Would this person prefer to include a graveside committal service?

Yes

No

Unknown

Free Text

Other Funeral Service Options

Please list any musical selections this person would like to include in their services.

Please list any special themes this person would like to include in their services.

Please list any poems, religious texts, or readings this person would like to be read at their services.

Is there a special story, personal thank you, or message of hope the person would like to be read during their services?

Veteran

US Military Service Information

Is this person or their spouse a veteran of the US Armed Forces?

Branch of Military

Do you have a copy of the veterans military discharge paperwork (DD-214)?

Yes, we do and will provide a copy to the funeral home

No

Unknown

Physician Information

Physician or Hospice Information

Is this person under a doctors care?

Yes

No

Unknown

Name of Primary Doctor

Has this person been admitted into a hospice program?

Yes

No

Name of Primary Doctor:

Free Text

Obituary

Would this person like an obituary published?

Would they like to have an obituary or short notice placed on the GFH website?

Yes

No

Unknown

Free Text

Information about the person who filled out this form:

First Name*

Last Name*

Relationship to the Individual this prearrangement form is for?

Address*

City*

State/Province*

Zip/Postcode*

Primary Phone Number*

Secondary Phone Number

Best Time to Reach Via Phone*

Email Address:*

Online Arrangement Form

If a Death Has Just Occurred

An At-Need Informational Guide to help plan a funeral

A Year of Grief Support

Online Arrangement Form

If a Death Has Just Occurred

An At-Need Informational Guide to help plan a funeral

A Year of Grief Support

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